Euthanasia*

1
Euthanasia

• Philosophy 2803
• Lecture VIII
• March 26, 2002
• This replaces the lecture originally labelled
  lecture VIII

2
Euthanasia

• A broad range of activities are sometimes
  classified as euthanasia
• Withholding or withdrawing treatment
• Actively ending someones life
• Providing someone with the means to end his/her
  life
• What all of them have in common is that they
  involve situations in which
• it is somehow deemed better that the person we
  are concerned with dies than that he or she lives
  and
• some course of action or inaction is undertaken
  with the understanding that it will bring about
  the death of the person

3
Is Euthanasia Ever Morally OK?

• If we give the term a broad reading, most people
  will answer yes.
• E.g., Suppose Tom has terminal cancer and that
  all conventional treatments have failed.
• Left untreated, he will die in a few days.
• However, there is an experimental drug that has
  shown some promise in treating cancers like his,
  but that also has some very unpleasant side
  effects.
• Few would argue that it is immoral if Toms
  doctors accept his wish to refuse this treatment.

4
What Matters Morally?

• The question thus becomes under what conditions
  is euthanasia morally acceptable?
• Discussion of this issue often turns on the type
  of euthanasia involved
• Active vs. Passive Euthanasia
• Voluntary vs. Non-voluntary Euthanasia
• Assisted Suicide

5
Active vs. Passive Euthanasia

• Active - roughly, involves killing a patient
• E.g., administering a fatal dose of morphine to a
  terminally ill cancer patient
• This is often what people have in mind when they
  simply speak of euthanasia
• Be careful to distinguish killing from murdering
  (wrongful killing) not all killings are
  murders
• Passive - roughly, involves letting a patient die
  
• E.g., failing to revive a patient who has signed
  a DNR order

6
Two Kinds of Passive Euthanasia

• (i) Withholding of Treatment e.g., not performing
  a needed surgery or not administering a needed
  drug
• (ii) Cessation of Treatment e.g., turning off a
  respirator
• Question  While i above seems clearly passive,
  why is cessation of treatment passive?
• Rachels "what is the cessation of treatment ...
  if it is not 'the intentional termination of the
  life of one human being by another'?" (375)
• Answers to this question tend to rest on claims
  about naturalness

7
Voluntary vs. Non-voluntary Euthanasia

• Voluntary - killing or letting die a competent
  person who has expressed a desire for this
  (usually over a sustained period of time).
• Non-voluntary - killing or letting die when the
  patient is unable to express such a desire
• Note there is a difference between involuntary
  and non-voluntary
• Involuntary euthanasia is not a seriously
  considered possibility

8
Assisted Suicide

• Not actually euthanasia, since the 'patient'
  ultimately kills himself or herself.
• The line between the two can, however, become
  very thin.  
• e.g., Dr. Jack Kevorkian's 'Mercitron'  
• Many of the same issues arise in considering
  assisted suicide as in considering euthanasia,
• e.g., the Sue Rodriguez case (pp. 366-372)

9
The Law

• Very roughly, the following summarizes the
  Canadian legal situation re. euthanasia
• voluntary passive euthanasia legal
• in fact, required
• voluntary active euthanasia illegal
• although see The Doctrine of Double Effect
• non-voluntary passive euthanasia legal
• under appropriate proxy decision
• non-voluntary active euthanasia illegal
• although again see The Doctrine of Double
  Effect
• assisted suicide illegal
• see the Sue Rodriguez case (pp. 366-372)

10
Voluntary Passive Euthanasia

• As noted, this is the least controversial form of
  euthanasia 
• It is now a well established principle that a
  competent patient has a right to refuse
  treatment, including lifesaving treatment
• But why?
• The short answer because of the central role of
  informed consent no consent, no treatment

11
A Longer Answer The Autonomy/ Dignity Argument
for VPE

• P1  A weakened, dying patient has lost control
  over her life in a significant way.
• P2  Allowing the patient control over how her
  life ends provides a way of preserving her
  autonomy and her dignity (as far as is possible).
  
• P3  Dignity and autonomy are very important
  values.
• C  In order to preserve the patient's dignity
  and autonomy, a terminally ill patient should be
  allowed to choose when treatment will be withheld
  or withdrawn.

12
Two Questions about the Autonomy/Dignity Argument

• Does this argument apply only to terminally ill
  patients?  If autonomy is so important then why
  shouldn't the patient's wishes be respected even
  if she is not terminally ill?
• E.g., The anorexic patient who refuses
  force-feeding
• A rational, healthy patient who simply wants to
  be allowed to starve himself to death.
• Because of the stress placed on informed consent,
  issues of competence are often raised.
• Those who think a request for cessation of
  treatment will be easily agreed to are often
  mistaken, particularly when the family or medical
  staff dont agree

13
Two Questions about the Autonomy/Dignity Argument

• Does this argument also support assisted suicide
  or active euthanasia?  
• A common response  No.  There is a morally
  significant difference between killing and
  letting die.  While autonomy provides a ground
  for allowing the person to die.  It provides no
  grounds for active killing.  
• The American Medical Association (1973)  While
  "the cessation of the employment of
  extraordinary means to prolong the life of the
  body ... is the decision of the patient and/or
  his immediate family," "mercy killing ... is
  contrary to that for which the medical profession
  stands." (372)
• James Rachels challenges this view.  He claims
  the distinction between killing and letting die
  is morally irrelevant. (372-376)

14
Rachels on Active vs. Passive Euthanasia

• "once the initial decision not to prolong his
  i.e., a patient with incurable cancer agony has
  been made, active euthanasia is actually
  preferable to passive euthanasia". (373)
• Objection But killing is morally worse than
  letting die!
• Response  Rachels claims that we have been
  misled by the fact that most actual cases of
  killing are morally worse than most actual cases
  of letting die
• Because of this, we have made the mistake of
  concluding that there is some deep moral
  difference between killing and letting die.

15
Cases

• (i) A unconscious patient will almost certainly
  die unless paced on a respirator. His family
  explain he has expressed a clear desire not to be
  placed on one. He is treated according to those
  wishes and dies.
• (ii) Case i, but the man is placed on the
  respirator before his family arrive. After his
  wishes are explained, he is removed from the
  respirator and dies.  
• Are these cases of killing or letting die?
• Are these cases morally different?

16
Cases

• (1) A man drowns his young cousin so that he
  won't have to split an inheritance with him.
• (2) Case 1, except, before he can kill him, the
  cousin slips and falls face down in the bathtub.
  The man just has to watch his cousin drown.  
• Are these cases of killing or letting die?
• Are these cases morally different?

17
Cases

• (a) In accordance with an ALS patient's wishes
  the doctors remove her from her respirator. She
  dies.
• (b) A greedy son removes an ALS patient from her
  respirator because he wants to collect his
  inheritance. She dies.
• Are these cases of killing or letting die?
• Are these cases morally different?

18
Is Rachels Right?

• Do the cases make a convincing argument that the
  difference between active and passive euthanasia
  is morally irrelevant?
• If so, then what is morally relevant?

19
Non-voluntary Euthanasia

• Until relatively recently, NPE NAE were largely
  looked upon as morally unacceptable
• Two ways in which NPE has become somewhat
  accepted
• By appeal to standards of personhood
• When the person is gone, NPE is generally
  accepted
• E.g., Harvard Brain Death loss of virtually
  all brain activity including brain stem
• By proxy
• Under certain conditions, a proxy decision to
  refuse or suspend treatment is generally accepted
  even if the person is still arguably there
• But recall Re. S.D. from lecture on consent,
  there are limitations on these decisions

20
The Case of Karen Quinlan

• 1975 - Quinlan goes into a drug induced coma
• Suffers anoxia (loss of oxygen to the brain)
  causing irreversible brain damage
• Required a ventilator/respirator to live
• Not brain dead, but in a persistent vegetative
  state (unconscious)
• Quinlans sister - "If Karen could ever see
  herself like this, it would be the worst thing in
  the world for her."
• Hospital - '1 in a million' chance of recovery
• Family sought to have her removed from the
  respirator, doctors hospital refused.
• 1976 - N.J. Supreme Court overturns a lower court
  decision and rules in favour of the Quinlans.
• Doctors 'weaned' her off the respirator in a
  successful attempt to keep her alive.
• Died of pneumonia - June 13, 1986

21
The Case of Nancy Cruzan

• June 11, 1983 - Cruzan, 24, suffers anoxia as a
  result of a car crash, enters a p.v.s.
• Kept alive by a feeding tube
• Parents sought permission to disconnect their
  daughter's feeding tube
• June, 1990 - U.S. Supreme Court rules that in the
  absence of 'clear and compelling' evidence of
  Cruzans wishes, it may not be disconnected.
• Publicity brings new witnesses (who knew her as
  Nancy Davis, her married name). 
• In a new trial, a lower court rules the 'clear
  and compelling' standard has now been met.
• Dec. 14, 1990 - N.C. is disconnected
  subsequently dies
• Many commentators thought that the fact that
  Cruzan required only a feeding tube (not a
  respirator) made a significant moral difference

22
Limits on Non-Voluntary Euthanasia

• NAE is still very controversial
• E.g., the Robert Latimer case
• The limits of NPE are also controversial
• E.g., Re. S.D.
• Robert Wendland (Topic of Groupwork)

23
A Continuum of Conditions

• Coma
• Brain activity, but no consciousness or
  wakefulness.
• Persistent Vegetative State (PVS)
• Wakefulness, but no awareness
• Minimally Conscious State (MCS)
• Wakefulness and minimal awareness
• Quite Different Locked-in Syndrome
• Full consciousness, but extreme paralysis

24
Minimally Conscious State

• a condition of severely altered consciousness in
  which minimal, but definite, behavioral evidence
  of self or environmental awareness is
  demonstrated.
• May be temporary or permanent
• Criteria (at least one of)
• following simple commands
• gives yes or no responses, verbally or with
  gestures
• verbalizes intelligibly
• demonstrates other purposeful behavior . in
  direct relationship to relevant environmental
  stimuli

25
Minimally Conscious State

• Unlike PVS, those in a MCS can feel pain, etc.
• meaningful, good recovery after 1 year in an MCS
  is unlikely
• being nonfunctioning and aware to some degree is
  worse than being nonfunctioning and unaware
• Ronald Cranford
• MCS is not a diagnosis it is a value judgment.
  
• Diane Coleman, president, Not Dead Yet

26
The Case of Robert Wendland

• NPE is now generally accepted when a patient is
  in a PVS
• Recently there have been controversies about
  whether NPE is appropriate in other sorts of
  conditions, specifically for patients in a
  permanent MCS
• One way of understanding these controversies is
  as linked to our conception of personhood the
  more restrictive the conception, the greater
  range of cases in which NPE is accepted

27
Robert Wendland

• Suffered brain damage in a car accident in 1993
• Wendland was supposedly in a permanent Minimally
  Conscious State (MCS)
• Could respond to simple commands.
• Wife and children claimed he never recognized
  them
• Mother claimed he would cry and kiss her hand
  during visits

28
Robert Wendland

• His mother opposed the attempt by his wife to
  have Wendlands feeding and hydration tube
  removed
• Wendland died in July 2001 of pneumonia before
  California Supreme Court could rule
• California Supreme Court eventually ruled against
  his wife

29
Question

• Assuming his wifes description of Wendlands
  condition was accurate, would NPE of Wendland
  have been morally acceptable?
• Why or why not?

30
The Doctrine of Double Effect (DDE)

• Suppose an action (e.g., giving a terminally ill
  cancer patient morphine) has some reasonably
  foreseeable outcome (e.g., quickening the
  patients death) and that it would be
  unacceptable to perform this action for the
  purpose of bringing this outcome about.
• The DDE claims that it may still be acceptable to
  perform this action, provided that the action is
  not performed for the purpose of bringing this
  outcome about.
• E.g., it may still be acceptable to give the
  patient the morphine provided that it is given in
  order to control his pain.
• The DDE is commonly, if not explicitly, appealed
  to in practice. In this sense, VAE. NAE. are
  quite often practiced.